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“The science of psychology has been far more successful on the negative than on the positive side. It has revealed to us much about man’s shortcomings, his illness, his sins, but little about his potentialities, his virtues, his achievable aspirations, or his full psychological height. It is as if psychology has voluntarily restricted itself to only half its rightful jurisdiction, and that, the darker, meaner half.”

— Abraham Maslow

What could we reasonably expect from mental healthcare, counseling, and psychotherapy? Is alleviating symptoms enough, or could we aim higher to strengthen character traits, develop resilience, and strive for long-term flourishing? Beyond addressing immediate problems, integrating positive psychology with clinical psychology has the potential to enhance us, too. Steven J. Sandage, Professor of Psychology of Religion and Theology at Boston University, shares how this knowledge is translated into practice.

“Mental healthcare in the United States largely functions from a medical model that focuses on problems and pathology, with treatment expected to focus on alleviating those problems and pathology. And the good news is that mental healthcare treatment has really been shown to be effective in reducing symptoms and mental health problems,” says Sandage. “It’s been less clear to practitioners and research funders in mental healthcare that there’s a need to also focus on strengths, wellbeing, growth, and meaning in life.”

Positive Psychology has been defined as the scientific study of the strengths that enable individuals and communities to thrive. The field is founded on the belief that people want to lead meaningful and fulfilling lives, cultivate what is best within themselves, and enhance their experiences of love, work, and play.

It’s gained cultural prominence over the last few decades, focusing on growth and fostering virtues such as gratitude, forgiveness, and humility. There are many other virtues, including justice, kindness, perseverance, reliability, and self-control.

“Patients talk about how to deal with relationship conflicts, have a more meaningful life, and dilemmas around virtues like hope,” says Sandage. Positive psychology counterbalances psychology’s tendency to focus on problems.

Clinical tools to thrive

Twenty-five percent of adults in the U.S. have a diagnosable mental disorder, making mental illness one of the most common health conditions, projected to cost the global economy $16 trillion dollars by 2030 in addition to incalculable suffering. 

“A lot of positive psychology research has developed outside of frontline mental health clinical contexts. Clinicians are sometimes not persuaded by the many studies on gratitude or forgiveness that are not in mental health settings,” says Sandage who is the Co-Principal Investigator for the Virtue & Flourishing Project.

“So, we've tried to bring measures of these virtues and flourishing into frontline mental health contexts and to begin to develop evidence based in these contexts.”

The project implements clinical measures of virtue and holistic forms of wellbeing and flourishing at different treatment sites and includes interviews, focus groups, trainings, research, and reliable and valid assessment information for clinicians to access.

 “At the Danielsen Institute, we developed a software platform where those measures, those assessment tools, can be transformed into user-friendly graphs and charts that clinicians can use with patients,” says Sandage. “In mental health treatment, the assessments that you would typically give to patients are focused on symptoms and pathology. If you don’t have some good assessment information about virtues or flourishing, many clinicians feel like they don’t quite know how to engage clients.” 

This approach looks at the whole picture. “That software platform integrates clinical practice patient data and our research…We’re excited to further test in a variety of clinical contexts with good collaboration with clinicians to give us further feedback,” says Sandage, adding that the assessment is repeatedly administered, and they’ve had patients come in who are really interested to see what their “virtue” scores look like.

“That changes the nature of the conversation. The therapists are still talking with patients about their depression or about their anxiety. But it’s not only that anymore,” says Sandage.

Positive psychology isn’t insensitive to deep suffering

“Some mental health clinicians, when you raise terms like positive psychology, virtue or flourishing, those words might sound rather naïve, idealistic, or even insensitive to them in the context of mental health patients who are really in the throes of deep and chronic suffering. So one of the things from our project is that it is important how we dialogue with clinicians about what topics like virtue and flourishing even mean,” says Sandage.

Positive psychology can have a beneficial impact on even severe mental illness.

Sandage references one of the site projects at McLean Hospital,where there are patients who suffer from borderline personality disorder – a serious mental health problem that can come with chronic suffering. 

“Our leaders of that project [including Harvard psychologist Mary Zanarini] have said that the patients most commonly invited to participate in that treatment study are struck that they’re actually being invited to work on developing strengths when so much of their prior mental health treatment has focused on their weaknesses and symptoms, and they’re often moved by the opportunity to counterbalance that with some strengths work,” says Sandage. 

“Learning to regulate intense emotions or reflect on one’s life is a part of the treatment. But I think long-term treatment that only focuses on alleviating symptoms may neglect to help people develop those capacities that will help them have a more well-rounded life. So, for example, this isn’t necessarily about helping these patients forgive someone who abused them, but it is about helping them learn to practice forgiveness in some of the relationships they really want to sustain in life.” 

He adds that some patients have never experienced a safe context to develop some of these virtues over time (six months, a year.) That’s a different model than someone telling you, ‘Hey, just be grateful.’ ‘Just forgive.’ 

Also, in psychotherapy, relational experiences are sometimes co-created between the patient and therapist and crucial to the scaffolding of virtue development. “For example, a patient getting really frustrated with their therapist, if the therapist responds non-defensively, the patients sometimes learn what it means to forgive in those relationships, even though they didn’t set out to have that be their treatment goal,” says Sandage. 

Dual factor approaches: envy & gratitude, narcissism & humility

The term “dual factor” refers to “the idea that mental health treatment might be able to both reduce suffering and also attend to how to develop holistic forms of wellbeing,” says Sandage. “It’s not either/or.”

For example, they’ve done training with clinicians on envy & gratitude. “We’re not just emphasizing the positive psychology topic. We’re taking a look at the complexities of how people suffer and struggle with envy and what is a healthy and authentic form of gratitude,” says Sandage.

“To suggest that you should just be grateful to everybody all of the time may not actually be a helpful frame for certain psychotherapy patients.”

On their training on narcissism and humility, “The advantage we found is some clinicians aren’t really interested in humility, but they’ll come to a training on narcissism. And then you get to talk about both sides of that. What we found helpful is to raise the question, is all narcissism bad or unhealthy? Could there be a healthy form of narcissism? And is all humility really good? What are authentic, mentally healthy forms of humility? And what are forms of humility that might be subjugating or oppressive, especially to certain groups?” says Sandage.

Dual factor treatment, such as working on fortitude, resilience, and other forms of coping amid the greatest hardships and stress, “can really help the patient,” says Sandage. “Sometimes the conversation starts with a clinician going over the assessment and noting that the client scores in these areas, and that picks up the conversation. And sometimes a client might say, oh, you have an assessment of forgiveness in this, and I hadn’t really thought about that, but I see that’s actually an area where I’m struggling or ambivalent.” 

Still, Sandage reminds us,

“Virtues are not like a microwavable dinner."

They’re not something that we just view quite simply today, and this afternoon I’m all healed… Just tell me two steps to forgiving my parent. Right? I can develop capacities for that over time, but it typically isn’t a quick fix,” says Sandage. “And so, we’re trying to outline ways that clinicians can thoughtfully engage clients about these complex topics.”

Holistic, complementary treatments

“I think that some of the best, really thoughtful positive psychology is inviting us to live whole lives. It’s the holistic frameworks that invite us to figure out what are some of the resources we can draw upon to feel like our lives are meaningful and to make contributions and connect with people who will be healthy in relationship,” says Sandage.

“The wellbeing or flourishing traditions are really important complements to mental health treatment…Treatment often tries to keep people from just reliving a painful past, but there can be therapeutic settings that continue to focus on the struggles that people are having, while neglecting strengths, growth, and meaning in life.”

Sandage concludes, “We are seeing evidence that these virtues, rightly understood and sensitively paced as part of treatment, might be crucial for the long-term mental health and wellbeing of patients.”